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Four blast cells are seen in this field. Notice the smooth chromatin pattern, nucleoli, high NC ratio and irregularly shaped nuclei. These blasts were observed in a spinal fluid sample from a patient with acute lymphocytic leukemia.

Blast cells may be seen in the spinal fluid when cell proliferation in acute leukemia or lymphoma spreads to the central nervous system. The arrows indicate the two blasts in this field. Notice the smooth chromatin pattern in the nucleus and prominent nucleoli in both cells. Notice that an Auer rod is present in the cytoplasm in the blast to the right. The Auer rod indicates that these blasts are myeloblasts rather than lymphoblasts. A segmented neutrophil and several red cells can also be seen.

Individuals with diabetes mellitus may excrete small amounts of protein in the urine which may signal the beginning of reduced glomerular filtration. Stabilizing the blood glucose level at this time may delay progression of diabetic nephropathy. Women in the last month of pregnancy may develop proteinuria as the first sign of impending eclampsia. Eclampsia is the gravest form of toxemia of pregnancy. The presence of protein in this situation must be evaluated by the physician in conjunction with other clinical symptoms.Benign transient proteinuria may be the result of: exposure to cold, strenuous exercise, dehydration, and/or high fever. Benign transient proteinuria may also occur during the acute phase of a severe illness.

A 70-year-old transient with productive cough, pleuritic chest pain radiating to the mid back, fever, and chills was seen in the emergency room. Expectorated sputum was sent to the laboratory for gram stain and culture. (Continue on next page)

A 40 year-old woman with a long history of diabetes mellitis developed swelling and erythema of the left lower leg following superficial abrasion of the skin after a fall. The patient developed high fever and mild prostration.The cellulitis of the lower leg is shown in the photograph.Note in the photograph that the acute inflammation is most evident as red areas of streaking at the sites of abrasion.Blood cultures were obtained that turned positive in 18 hours.

Newfield RS. Vargas I. Huma Z.: Eikenella corrodens infections. Case report in two adolescent females with IDDM. Diabetes Care. 19:1011-3, 1996OBJECTIVE: To alert physicians caring for patients with diabetes to the microorganism Eikenella corrodens and to discuss the appropriate preventive and therapeutic measures to take against this potentially morbid opportunistic Gram-negative bacilli.CASES: We present two cases of extra-oral E. corrodens infections in adolescent females with IDDM. The first patient had diabetes of 4 years' duration, which was moderately well controlled. Chronic finger biting resulted in a complex felon that evolved gradually and worsened while the patient received cephalexin orally. Delay in seeking further intervention resulted in necrosis of her distal fingertip and nail bed. The second patient had poorly controlled diabetes for 5 years. She developed an acute thigh abscess at an insulin injection site that resolved after drainage and intravenous antibiotics.CONCLUSIONS: E. corrodens commonly inhabits the human oral cavity and becomes a pathogen mostly when host defenses are impaired, causing abscesses and infections that are at times fatal. Patients with IDDM are compromised hosts and with daily microtrauma to their skin via glucose monitoring and insulin injections, are prone to develop E. corrodens infections that can be introduced through oral secretions by licking or biting their skin. Educational efforts aimed at preventing exposure of traumatized skin to oral secretions can minimize the risk of E. corrodens infections in compromised hosts.Early intravenous administration of antibiotics, bearing in mind E. corrodens resistance to clindamycin, metronidazole, and other antibiotics, coupled with prompt surgical intervention, is essential in successfully managing E. corrodens infections.

Disseminated Intravascular Coagulation (DIC) is best described as a disorder of consumption, because clotting factors are depleted from the blood. Basically, clotting occurs randomly throughout the body, as opposed to just in the localized areas where vascular damage has occurred, consuming clotting factors and other components such as platelets in the process. Symptoms may range from a mild bleed, to severe, profuse bleeding, primarily dependant upon the availability of clotting factors. As more and more coagulation factors and components are consumed, the disorder progresses and symptoms worsen. Most heavily impacted are the levels of factors I, V, and VIII as well as the number of available platelets. Clinically, DIC is detected via an elevated (positive) FDP, positive D-dimer test, a prolonged PT and APTT, plus the manifestation of hemorrhagic episodes. DIC is diagnosed as two primary types, acute and chronic. Acute DIC manifests in a few hours or a few days, has a high mortality rate, and is seen in infections, obstetric complications, liver disease, and tissue injury. Chronic DIC is a secondary condition to some other disease state. Once you treat the primary disease, this type of DIC will go away. Treatment is often factor replacement therapy through the use of fresh frozen plasma and/or cryoprecipitate.

After the initial infecting incident, HBV enters an incubation period lasting an average of 60 to 90 days.Following this period is the onset of acute hepatitis, which inflames the liver and causes prolonged illness, often progressing to jaundice.Most infected individuals recover completely, but about 10% get chronic hepatitis, which lasts for years. Chronic hepatitis may result in cirrhosis or liver cancer. Both are potentially fatal.

Up to 1% of the U.S. population harbors the Hepatitis B virus in their bloodstream. In 1990, workplace exposure gave rise to an estimated 8,000 cases of HBV resulting in 200 to 300 deaths from acute and chronic HBV. So occupational exposure to HBV is a serious problem.

Acute hepatitis panel: Hepatitis A antibody (IgM) Hepatitis B core antibody, IgM (HBcAb) Hepatitis B surface antigen (HBsAg) Hepatitis C antibody

Heinz bodies are 1-3 um particles of denatured hemoglobin settling eccentrically, usually close to the red cell membrane. They are found in erythrocytes in unstable hemoglobin disorders, acute drug induced hemolysis, and following splenectomy. Their formation may be exaggerated by in-vitro incubation of a fresh blood sample with phenylhydrazine. Heinz bodies, as pictured here, are identified using a supra-vital stain, such as new methylene blue or cresyl violet. Bite cells, visible with Wright-Giemsa staining, are visual reminders that the spleen is functional and has pitted the aberrant chunk of hemoglobin from the circulating erythrocyte.

There are a number of abnormalities of sperm morphology. Abnormal heads can include enlarged head, double head, round head, constricted head, amorphous head, pinhead, and acute tapering forms. There are also heads with abnormal numbers of vacuoles. Midpiece abnormalities include distended and thin midpiece regions. Abnormal tails include short tails, double, triple or multiple tails, coiled tails, broken tails, or absent tail. Cytoplasmic droplets are also seen in some specimens. These are large regions of cytoplasm just below the head assumed to represent failure of complete sperm maturation or a sign of either toxicity or oxidation. There have also been reports that cytoplasmic droplets may be artifacts from the fixation and staining for morphology analysis.

Waxy casts appear as cylinders of smooth, highly refractive material. They are yellow, homogeneous and their ends may be square or broken off. Cracks may occur within the cast, giving it a segmented appearance. Waxy casts are believed by some to be the final stage of degeneration of the fine granules of granular casts. Since the granules need time to degrade, this finding implies localized nephron obstruction. Waxy casts are seen in chronic renal failure, and acute and chronic renal allograft rejection. Unusually broad waxy casts are known as renal failure casts. These very broad casts are created in the dilated tubules seen in end-stage renal disease.

Another type of epithelial cell is the renal tubular epithelial cell. The proximal and distal convoluted tubules are the sites of origin for one form of these cells. They occur singly and are large (14-60 microns). Papancolaou stain is useful in distinguishing renal tubular cells from other mononuclear cells in urine. Increased numbers of proximal and distal convoluted renal epithelial cells are seen in cases of acute tubular necrosis and certain drug or heavy metal intoxication.

A 17-year-old young woman was admitted to the hospital with abdominal pain and a tentative diagnosis of appendicitis.The total white blood count was 14,500 cells/cumm with a left shift and neutrophils with changes tagged by the arrow in the photographs (see blue arrow).The bluish-staining, blurred accumulations in the cytoplasm (Doehle bodies), are located at the cell periphery in neutrophils with toxic changes.Doehle bodies are remnants of endocytoplasmic reticulum and are products of cytokine activity in the induction and shortened activity of neutrophil activation.They are often present in conditions with increased neutrophil lysosomal activity, manifest as toxic granulation.In this case, the presence of Doehle bodies serves as markers for infection-induced leukocytosis and supports the diagnosis of acute appendicitis.

Doehle bodies are discrete, round or oval aggregates at the cytoplasmic periphery of neutrophils (blue arrows in figures). They stain sky blue with Romanowsky's stain and often may be deceivingly inconspicuous. In electron-micrographs, Doehle bodies are recognized as lamellar aggregates of rough endoplasmic reticulum. Although not considered a marker for leukemia, Goudsmit, et al (Brit J Hematol 20:447-562, 1971)reported their presence in family members, 2 sisters and 3 brothers. Two of the brothers died of acute myeloblastic leukemia. These testimonials indicate that Doehle bodies, when identified in peripheral blood smears, should be taken seriously so as to stimulate a clinical investigation of the patient.